Nokea
The nurse in the outpatient clinic plans care for a 65-year-old woman with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to
- A. increase the amount of calcium in her daily diet.
- B. increase the amount of vitamin D in her daily diet.
- C. increase the amount of time she is exposed to sunlight.
- D. increase her activities that involve weight-bearing.
Correct Answer: D
Rationale: Weight-bearing activities stimulate bone formation, critical for osteoporosis, and improve mobility post-CVA. Options A, B, and C support bone health but are less impactful than exercise for addressing both conditions.
You may also like to solve these questions
A client arrives at the emergency room with an HR of 120, an RR of 48, and hemoptysis. The nurse should give priority to:
- A. Obtaining a history of the current illness
- B. Applying oxygen via mask
- C. Obtaining additional vital signs
- D. Checking arterial blood gases
Correct Answer: B
Rationale: Hemoptysis and tachypnea suggest respiratory distress, so oxygen administration is the priority to stabilize the client.
The nurse is caring for a client with a history of HIV/AIDS.
- A. Which laboratory finding is most concerning for a client with HIV/AIDS?
- B. CD4 count of 150 cells/mm³.
- C. Viral load of 10,000 copies/mL.
- D. White blood cell count of 5,000/mm³.
- E. Hemoglobin of 12.0 g/dL.
Correct Answer: A
Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
- A. Which nursing action is the highest priority for a woman in labor with a sickle cell crisis?
- B. Administer oxygen.
- C. Turn her to the right side.
- D. Provide adequate hydration.
- E. Start antibiotics.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.
A newborn is to be discharged in the AM.
The nurse should teach the child's mother to perform which of the following actions?
- A. Apply a sterile gauze dressing with petroleum jelly to the cord.
- B. Position the diaper over the umbilicus to keep it dry.
- C. Clean the cord several times a day and expose it to air frequently.
- D. Apply erythromycin ointment to the cord several times a day.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below the umbilicus (3) correct-encourages drying and helps to prevent infection (4) antibiotic ointment is unnecessary